Saturday, June 2, 2012

All things General Med!

Posted by Beejal at Saturday, June 02, 2012

Hi everyone!
I meant to post a long time ago, but I got busy pretty quickly!  To give you all a heads up, below is my rotation schedule:
Rotation 1: General Medicine (UMHS, Engle)
Rotation 2: Hospital Pharmacy, former “Institutional” (St. Joes Ann Arbor, West)
Rotation 3: Peds Hem/Onc (Mott, Howell)
Rotation 4: Amb Care Cardiology (VA Ann Arbor, Brenner)
Rotation 5: Nontraditional Geriatrics (St. Louis, MO, Levy)
Rotation 6: Critical Care-Cardiac ICU (UMHS, Butler)
Rotation 7: Off
Rotation 8: Drug Information (DMC)

By now I have finished 2 weeks of my General Medicine rotation.  If I have been told accurately, this rotation was only created 1 year ago, but it has been a very valuable experience for me so far.  The idea behind it is to know what types of responsibilities a decentralized clinical pharmacist has at an academic hospital.  These pharmacists follow a number of services and monitor those patients’ medications.   They also have a staffing role, but that is covered in the “Hospital Pharmacy” rotation.

Preceptors, Sites, and Service assignments! When signing up for this rotation, Dr. Engle will always be the preceptor assigned to you.  She is indeed one of the preceptors available for the rotation but there are usually 4-5 other preceptors that will get assigned students as well.   In signing up for this rotation, there is a chance that you will have your rotation at Mott so an email was sent out before rotations began asking our preference for being at UMHS or Mott.  Assignments were dependent on both our preferences and whether our rotation schedules had other Mott rotations.  Assignments were distributed the week before the rotation began.  I preferred to be at UMHS because I have only 1 other rotation at UMHS (critical care) and already have a Mott rotation.

The first day of rotation we were all assigned services.  For the UMHS students, there are 6 students split between 3 preceptors.  My preceptor happens to be Dr. Engle, and I like her a lot!  All of the preceptors and pharmacists are very helpful and good teachers, and very understanding of the fact that this is our first APPE ever!  Anyways, the service you get depends on the services that your preceptor is assigned to.  Pharmacists/Preceptors change services every 2 weeks, so you will change with them (You will follow 1-2 services for 2 weeks, and then switch to another one for 2 weeks).  

What is rounding like? You’ll find that not all of the services go on patient rounds.  I started out on a rounding service.  Rounds consist of an Attending Physician, lead resident, 2 interns, 2nd year med student, a 1st year med student, and pharmacy.  Dr. Engle rounded with me for my first day, and then sent me on my own for many of the rest of the days.  This was pretty daunting, and I almost had her come for a 2nd time with me- but I eventually mustered up the courage to dive right in.  It wasn’t so bad, especially because the physicians really do realize we’re new at this.  It helps to have medical students there too because we’re all at a similar education level.  You’re not the only amateur there, and the physicians and interns usually are asking you questions that they already know the answers to, so you’re not necessarily compromising a patient’s care by not knowing.  (They won’t tell you the answer, you’ll still have to look it up! Haha)  The rule of thumb that you will be told often is, each medical student and intern will be assigned patients on the service.  If you have a recommendation or an answer to a question that you looked up, you should be speaking to the medical students first.  If for some reason you cannot do that, then pursue the interns, then the lead resident, then the Attending. 

On a day-to-day basis... it’s fairly similar to Regal’s Internal Medicine rotation described in one of the posts below by David.  My schedule varies depending on how many patients I am following and how many of them are new admits.  I come in at 7am and follow up on morning labs and overnight events until 7:40ish. I then go over each patient with Dr. Engle about recommendations to the team, and then head to rounds at 8am.  Rounding usually ends between 10 and 10:30am.  I come back to the pharmacy, and for the rest of the day I’m looking up questions I didn’t know during rounds and getting back to the med students or interns with an answer.  I’m also following up and working up patients, documenting and addressing alerts in Theradoc, and doing patient educations.  For 2-3 days a week, we also get all of the General Med students together to have preceptor-lead topic discussions.  After rounds is generally slow, but 8am rounding services have a particularly unique time commitment.  There are many General Med services, and they take new admissions on a cycle system (which I haven’t figured out the details to yet).  New admissions tend to happen between 2 and 7pm a few days a week, so around 7pm at home I check for new admits and start working them up.  It makes my 7am morning a lot easier since I only have about 30 mins before I have to meet with Dr. Engle to discuss.  Beginning work ups at home is especially helpful when I follow a larger number of patients (highest I’ve gotten so far is 13).  Moral of story: when you're assigned an 8am rounding service, expect to spend some time after work especially at the beginning to keep you on track and prepared for the next day.

Reflections of my first service! I’ve just finished 2 weeks on my rounding service.  I really enjoyed it because the team was fun, and the Attending and interns are very good teachers.  Everyone on the team is learning from each other, and once you go on rounds for a few days you’ll realize you remember more than you thought you did.  You’ll also find yourself saying “I don’t know, but I will look it up and page you” A LOT!   

I like that this rotation is general (no pun intended) so that I’m pulling from different disciplines.  Further, I think I’m very lucky to have this as my first rotation, because it’s given me a lot of practice with all types of specialties: coag, cardio, ID, etc.  It seems like every one comes in with a UTI and pneumonia even if it's not their chief complaint!  We also spend a lot of time figuring out if antibiotics are appropriate, and if the dosing is appropriate.  I spend every day looking at vanco troughs, to adjust vanco doses.  I haven't had to work with Aminoglycosides yet, but I've heard that with the next service it's more common.  Finally, this rotation has also given me a lot of practice talking to the medical team and becoming more confident.

My next service: Beginning Monday (3rd week), I will be changing assignments to a non-rounding service.  Those rounds consist of the physicians meeting in a conference room to discuss patients and if you have a recommendation, you directly talk to the Attending (usually).  From what I’ve seen so far (and I could be wrong), these teams don’t go see the patients together, don’t have medical students, and may not have interns.  I anticipate that I won’t need to follow patients after I leave UMHS because these rounds begin at 1pm, giving me plenty of time between 7am and noon to work up patients.  I also anticipate being able to handle more than 13 patients, since I won’t be spending 2.5 hours rounding!

I really enjoyed rounding and seeing the patients, so I will miss my first service but look forward to a different rounding experience!  I plan to post my next blog after my non-rounding service to offer a comparison!  

Sorry for such a long post, but hopefully it’s valuable for some of you out there!  Back to my journal club article: Effect of Emperical Treatment with Moxifloxacin and Meropenem vs Meropenem on Sepsis-Related Organ Dysfunction in Patients With Severe Sepsis.

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